                                 CODE OF VIRGINIA

MINIMUM QUALIFICATIONS FOR INDEPENDENT REVIEW ORGANIZATIONS (§ 38.2-3565)

A. An independent review organization shall have and maintain written policies
and procedures that govern all aspects of both the standard external review
process and the expedited external review process and that include, at a
minimum:

   1. A quality assurance mechanism in place that: ensures that external reviews
   are conducted within the specified time frames and required notices are
   provided in a timely manner, ensures the selection of qualified and impartial
   clinical reviewers to conduct external reviews on behalf of the independent
   review organization and suitable matching of reviewers to specific cases and
   that the independent review organization employs or contracts with an adequate
   number of clinical reviewers to meet this objective, ensures the
   confidentiality of medical and treatment records and clinical review criteria,
   and ensures that any person employed by or under contract with the independent
   review organization adheres to the requirements of this chapter;

   2. A toll-free telephone service to receive information on a 24-hour-a-day,
   seven-day-a-week basis that is capable of accepting, recording, or providing
   appropriate instruction to incoming telephone callers; and

   3. Provisions for maintaining records and providing reports to the Commission
   in accordance with the requirements set out in &#xA7; 38.2-3568.

B. All clinical reviewers assigned by an independent review organization to
conduct external reviews shall be physicians or other appropriate health care
providers who shall meet the following minimum qualifications:

   1. Be an expert in the treatment of the covered person&#8217;s medical
   condition that is the subject of the external review;

   2. Be knowledgeable about the recommended health care service or treatment
   through recent or current actual clinical experience treating patients with
   the same or similar medical condition of the covered person;

   3. Hold a nonrestricted license in their health care field in a state and, for
   physicians, a current certification by a recognized American medical specialty
   board in the area or areas appropriate to the subject of the external review;
   and

   4. Have no history of disciplinary actions or sanctions, including loss of
   staff privileges or participation restrictions, that have been taken or are
   pending by any hospital, governmental agency or unit, or regulatory body that
   raise a substantial question as to the clinical reviewer&#8217;s physical,
   mental, or professional competence or moral character.

C. An independent review organization may not own or control, be a subsidiary
of, or in any way be owned or controlled by, or exercise control with, a health
benefit plan, a national, state, or local trade association of health benefit
plans, or a national, state, or local trade association of health care
providers.

D. Neither the assigned independent review organization nor any clinical
reviewer assigned by the independent organization may have a material
professional, familial, or financial conflict of interest with any of the
following that is the subject of the external review:

   1. The health carrier;

   2. The covered person or his authorized representative;

   3. Any officer, director, or management employee of the health carrier;

   4. The health care provider, the health care provider&#8217;s medical group,
   or the independent practice association recommending the health care service
   or treatment;

   5. The facility at which the recommended health care service or treatment
   would be provided; or

   6. The developer or manufacturer of the principal drug, device, procedure, or
   other therapy being recommended.

E. An independent review organization shall be accredited by a nationally
recognized private accrediting entity that has standards that the Commission has
determined are equivalent to or exceed the minimum qualifications of this
section. The following shall apply with regard to accrediting entities:

   1. Upon request, a nationally recognized private accrediting entity shall make
   its current accreditation standards available to the Commission or the NAIC.
   The Commission shall initially and periodically review the accreditation
   standards of the nationally recognized private accrediting entity to determine
   whether the entity&#8217;s standards are, and continue to be, equivalent to or
   exceed the minimum qualifications established under this section;

   2. The Commission may accept a review conducted by the NAIC for the purpose of
   this determination. The Commission may exclude any private accrediting entity
   that is not reviewed by the NAIC; and

   3. The Commission may approve independent review organizations that are not
   accredited by a nationally recognized private accrediting entity only if there
   are no acceptable nationally recognized private accrediting entities providing
   independent review organization accreditation.

F. An independent review organization shall be unbiased. An independent review
organization shall establish and maintain written procedures to ensure that it
is unbiased.

HISTORY: 2011, c. 788.